ELENA SMITH
Subscriber on policy B04M000551
Claims
1
Attributed to this person
Charged
524.00
Total submitted
Denied
0.00
1 denied claims
Patient responsibility
340.60
Reported on the 835
Patient responsibility is the amount reported on the 835 as assigned to the patient — deductible, coinsurance or copay. It is not proof that the provider billed the member, that the member owes it, or that it was collected, and it is kept separate from denied amounts throughout.
Who this is
| Field | Value |
|---|---|
| Name | ELENA SMITH |
| Role on the policy | Subscriber |
| Policy | B04M000551 |
| Date of birth | 21 Mar 1958 |
| Plan | BRONZE EPO |
| Covered from | 3 Apr 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 50 · Other | 1 | 340.60 |
| Total | 340.60 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0002431 | 31 Oct 2025 | 524.00 | NORTHSTAR MUTUAL | CARC 50 · MEDICAL_NECESSITY | 0.00 |